Provider Demographics
NPI:1508085291
Name:BOULEVARD PSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:BOULEVARD PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:EAVES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:913-499-4302
Mailing Address - Street 1:6240 W 135TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-4849
Mailing Address - Country:US
Mailing Address - Phone:913-499-4302
Mailing Address - Fax:913-499-4304
Practice Address - Street 1:6240 W 135TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-4849
Practice Address - Country:US
Practice Address - Phone:913-499-4302
Practice Address - Fax:913-308-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS 811103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS19320048OtherBLUE CROSS BLUE SHIELD
KSS987424Medicare ID - Type Unspecified